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Laparoscopic repair of ureteral injuries
Harout Margossian1, Tommaso Falcone, Mark D Walters
1Department of Obstetrics and Gynecology, Lutheran Medical Center, Brooklyn, New York, USA.
Study Objectives:
To evaluate the laparoscopic approach for repairing ureteral injuries, and assess the effect of ureteral dissection (ureterolysis) on tissue healing.
Design:
Randomized animal study (Canadian Task Force classification I).
Setting:
Biological Resources Unit, Cleveland Clinic Foundation.
Subjects:
Ten pigs.
Intervention:
In all animals, the pelvic segment of the right ureter was completely dissected off the pelvic sidewall and peritoneum. In group A, both pelvic ureters were divided with scissors and repaired over a stent; in group B the ureters were coagulated and anastomosis was performed after resection of the necrotic segment. Laparoscopic intracorporeal suturing techniques were used for end-to-end ureteral anastomosis.
Measurements And Main Results:
All animals survived without complications. Ureteral stents were removed 4 weeks after repair. Creatinine level and retrograde pyelogram performed before injury and 12 weeks after repair were compared. At necropsy anastomoses were evaluated for leak, pressure flow studies, and histopathology. All anastomoses were patent with no leak. Although serum creatinine level increased significantly after repair (p = 0.001), this increase never reached levels found in renal failure, and all animals continued to do well and have good appetite (mean increase in body weight 20.3 +/- 6.2 kg). Mild hydronephrosis was diagnosed in three kidneys, all on the right side. Mild ureteral dilatation occurred bilaterally; it was significant on the right side (3.8 +/- 3.8 mm, p = 0.05) but not on the left (1.7 +/- 2 mm, p = 0.3). Results of pressure flow studies did not reveal significant obstruction at anastomoses. Healing around the dissected right ureter was marked with dense fibrosis, adhesions, and scar formation. On histopathology the right ureter showed more urothelial abnormalities than the left, with marked fibrosis and sclerosis in the muscularis and adventitial layers.
Conclusion:
Ureterolysis may interfere with the healing process of ureteral injuries by increasing fibrosis and adventitial scarring. Laparoscopic repair of these injuries is feasible and safe.
